Documenting, Reporting and ConferringPrepared By: Princess
Celmea S. Aspuria
Document
A written or printed paper that bears the original, official, or
legal form of something and can be used to furnish decisive
evidence or information.
Nursing Documentation
Accurate documentation of patient symptoms and observations is
critical to proper treatment and recovery. Entries written on a
patient's medical record are a written, legal, permanent
document.
Nursing Documentation
If documentation is poorly or inaccurately entered into a
medical record, patient may receive improper or potentially harmful
care.
Nursing Documentation
What you document as fact in a medical record, is directly used
by physicians, nurses, and physician assistants to plan, implement,
and evaluate their patient's course of treatment.
Reporting
To make or present an often official, formal, or regular account
of. To relate or tell about; present: report one's findings.
Conferring
To hold or take part in a conference or consult together
Case
Philippe Baron
Philippe is a 52-year-old man being discharged from the out
patient surgery department after undergoing a colonoscopy for
removal of three polyps. He will be going home with his wife who is
a nurse, and they both require discharge teaching.
Focusing on Blended Skills
Cognitive Skills
Knowledge of colonoscopy as a diagnostic measure and need for
follow-up Ability to incorporate knowledge of potential
post-colonoscopy complications when developing a discharge teaching
plan
Technical Skills
Strong assessment skills to identify potential risk factors that
may affect a patients care
Interpersonal Skills
Strong interpersonal skills to establish a trusting
nurse-patient relationship grounded in responsible caring Ability
to communicate to patients, their families and professional
caregivers a greater concern about the patient and his or her
well-being that about rote documentation of the plan of care
Interpersonal Skills
Ability to demonstrate that what matters is communicating the
plan of care so that coordination of care is achieved Ability to
establish collaborative respectful relationships with healthteam
members to promote quality care
Interpersonal Skills
Ability to demonstrate respect for the patients human dignity
and autonomy throughout the patients care
Ethical and Legal Skills
Ability to incorporate ethical and legal principles that guide
decision making related to a patient needing discharge teaching
Dialogue
Nurse: Good morning Mr. and Mrs. Baron. Mr. Baron and Mrs.
Baron: Good morning nurse.
Nurse: Mr. Baron, how are you feeling today? Mr. Baron: I still
feel quite sleepy, but Im excited to go home already!
Nurse: Well of course, Sir, you will be discharged from the
hospital today. But before that, we have to focus first on your
discharge teaching, along with Mrs. Baron. Undergoing colonoscopy
also needs proper management after the procedure.
Mr. Baron: I see. Well, Id be happy to hear your teaching. Mrs.
Baron: Yes. Wed be glad to listen to your discharge teaching right
away.
Nurse: First of all, Mr. Baron is not allowed to drive on his
way home. He will still be drowsy from the medication given to him
during the procedure. Mrs. Baron: Oh yes, thats right. That means
Ill be driving us home honey. (Looks at Mr. Baron) Mr. Baron:
(looks at wife) Okay dear. (Looks at nurse) Go on nurse,
continue.
Nurse: You must also not drink alcohol or make any important
decisions until after tomorrow. This is because it takes some time
for the medication to work its way through your system.
Nurse: Alcohol in combination with any sedation you may have
received is likely to make you much more sleepy than usual. Mr.
Baron and Mrs. Baron: (nods)
Nurse: You may resume your normal diet as well as your normal
daily activities. Mrs. Baron: How about his medications?
Nurse: We advise against taking aspirin or anti-inflammatory
drugs in any form for the next week. You may take stool softeners
and bran but do not take strong laxatives. Mr. Baron: How about my
stool, nurse? Would the procedure done to me have any effect on
that?
Nurse: Your colon has been completely emptied and you should not
expect necessarily to start to have normal bowel function for two
to three days. Bowel actions after that should rapidly return to
normal. Mrs. Baron: How about the things that we should watch out
for?
Nurse: When there is severe pain or vomiting, passage or
vomiting of blood, and temperature greater than 38 degrees, please
report it to your doctor immediately.
Nurse: However you may also experience gaseous discomfort. It is
normal and expected after the procedure. Passing flatus and
belching is encouraged. Bending your knees while lying down may
help relieve the flatus.
Nurse: You may also develop a lump or redness at the site of
where medication was administered during the procedure. Apply a
warm compress to the area and call your physician in 24 hours if
the situation has not improved. That would be all Mr. and Mrs.
Baron. Are there any questions you would like to ask?
Mr. Baron: None. Thank you Mrs. Baron: Thank you, nurse. Ill
keep those things in mind. Nurse: Thank you Mr. and Mrs. Baron.
Take care on your way home. Have a great day!
Thank You!
